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flat feet

AUTHOR: Marc Mitnick DPM

REVIEWED BY: Podiatric Medical Review Board

--> flat feet

pes plano valgus, adult acquired flat foot

Flat feet more commonly known as fallen arches is a condition found in both children and adults. In most situations, when the patient is non-weight bearing, there will be some sort of discernible arch, however, that arch quickly disappears when the patients stands up. This distinction needs to be made because there are individuals who exhibit a more rigid flat foot both standing and sitting. These individuals generally have more symptomatic problems and this discussion will briefly look into that condition at the end.

The ‘flexible flat foot’ that we are going to discuss here may occur in one or both feet, and the degree of flattening can vary between the two feet. In many people flat feet are not an issue at all and these people go through life without any foot problems. In others, the long term effects of flat feet can not only lead to foot and ankle pain, but many people will also experience knee, hip and lower back pain as a result of their feet being flat.

Flat feet are common if not almost normal in infants and toddlers simply due to the fact that the arch of the foot has not yet developed. The arch generally will develop during childhood as part of a normal relationship between the foot’s muscles, tendons, ligaments and bone. It is advocated by many that young children should be given the opportunity to walk barefoot particularly over uneven terrain (eg: the beach) in an effort to help strengthen the muscles that originate in the foot.

Theoretically, wearing orthotics at a young age would help develop an arch, but it is generally not a practical maneuver in that the child would have to be wearing his orthotics ALL the time. The reality is that never happens if you stop and think about how often a child is barefoot, at times such as in the morning and evening hours at home, or while at the beach, etc.


What Should You Look for

YOUNG CHILDREN Even though young children will tend to walk flat footed their gait should be observed for any abnormal signs such as limping, clumsiness in gait, or an excessive ‘knock-kneed’ gait. The parent should also observe whether or not the child tends to tire easily during walks or complains of foot or leg pain during extended walks. Parents should also observe their children's shoes for abnormal wear patterns. Additionally, many children who are excessively pronated will experience night cramps. In my practice, this is usually the complaint that makes parents first aware of their child's excessive pronation and brings them into the office.

PRE-TEENS AND TEENAGERS Usually in this age range, parents bring the children in for treatment of their flat feet because the kids have started playing sports and the demands of a lot of running are now beginning to manifest themselves with foot and leg pain as a result of flat feet. The main complaint is that when it comes to running, they cannot seem to keep up and they have pain in their feet and legs that lasts long after the game. Shin splints and heel pain are two common symptoms that are result of flat feet in the young athlete.

ADULTS Flat feet in the adult may either be a direct extension of the condition from youth or can be caused by other factors. These factors include injury, disease such as arthritis or neurological disease, poor biomechanics (a fault in the way the foot functions during gait), excessive weight gain, occupational demands placed on the feet, and hormonal changes seen during pregnancy along with the associated weight gain.

As previously stated a distinction is made in the type of flat foot that a person may exhibit. A rigid flatfoot is one where the foot is flat both on and off weight-bearing as opposed to a flexible flatfoot where off weight-bearing there is some sort of arch but upon standing the arch flattens out.

Note the following diagram of a foot that has flattened out. Because of the excessive movement of the foot and lower leg in the direction of the three arrows this throws off the way the foot will function in the gait cycle.

acquired flatfoot

Because the foot is over stretching or flattening out it is putting excessive strain on the muscles and ligaments that “hold” the foot together. In doing so it forces the muscles in the foot and lower leg to work in an abnormal fashion causing a variety of problems. In addition to the problems already mentioned in children and teens, conditions such as bunions , hammertoes , midtarsal fault, calluses on the ball of the foot can have a flat foot component to their formation. Additionally, runners knee is knee pain seen in flat feet and occurs in both children and adults.


A worsening state of flat feet in the adult is known as adult acquired flat foot, medically known as posterior tibial dysfunction. The etiology, or cause behind its formation, is not completely understood. It can end up being a very difficult condition to treat. In addition the condition seems to have become more prevalent over the last 20 years. The foot is completely flat weight bearing or non-weight bearing.

For years the consensus was that this condition was caused by a loss of function of the posterior tibial muscle, also known as the long flexor tendon, see anatomy diagrams.

In more recent years the general thinking has moved more to a combination of non-function of various parts of the foot primarily the ligament attachments in the rear portion of the foot. This line of thinking would make sense since surgically repairing the tibialis posterior muscle alone rarely solves the problem.

The picture below demonstrates a typical adult-acquired flatfoot.

anatomical flatfoot

Since the foot does not flatten out and collapse like a pancake overnight, it is a progressive deformity and treatment should be instituted according to the degree of deformity that is presented to the doctor. In other words, a patient with a mild case should not look at surgery as a first option, whereby a person with an advanced case may have no other choice other than surgery because anything less will just not work.

consequences in gait from tibialis posterior dysfunction

  • Contact Phase-loss of shock absorption as the heel hits the ground and premature loading of midtarsal joint or middle portion of foot.
  • Midstance Phase-increased collapse of middle portion of foot resulting in breakdown of joints and ligaments and shearing of soft tissue all resulting in pain.
  • Propulsive Phase-as the foot "pushes off" it does so off the inside of the foot which results in loss of propulsive power.
  • Swing Phase-as the affected foot swings forward it results in decreased acceleration of the limb and increased stress on the weightbearing limb.

see gait cycle

INITIAL TREATMENT In the early stages of deformity when you first experience tendonitis, swelling and pain, simple techniques like ice, immobilization and anti-inflammatory medication is probably all that is needed. X-rays may be very helpful in determining the degree of deformity, as well as muscle testing in predicting the possibility of worsening. At this point a simple orthotic may be all that is necessary in stabilizing the foot.

ADVANCED TREATMENT In more advanced stages once the inflammation is reduced thru ice and medication an ankle foot orthosis may be needed to give better support to the mid part of the foot, the rear portion of the foot and the ankle.

Once a patient presents with a completely “broken down” foot conservative therapy will not help. It may offer short term relief but ultimately the patient will have to consider surgical intervention ranging from repair of the tibialis posterior tendon, to associated ligament repair, to bone fusions, where certain bones in the mid and rear portion of the foot are fused to “hold” the foot in an upright position.

There is a procedure which is gaining popularity, known as a subtalar arthroresis. In this procedure a titanium device is placed in the subtalar joint which is the joint that controls pronation or the excessive flattening out of the foot. This device acts as a wedge which then limits the motion of the subtalar joint and thus reduces excessive pronation.

The indications for this procedure are pediatric flexible flat foot, adult flexible flat foot and tibialis posterior dysfunction. The key criteria here is that the foot must be a flexible flat foot (vs. a rigid flatfoot). A flexible flat foot is a foot that is flat during weight bearing but will have some degree of arch when non-weight bearing. A rigid flatfoot is always flat whether weight bearing or non-weight bearing and thus is not a candidate for this procedure.

The procedure itself is a relatively simple procedure but does require the patient to be non-weight bearing for one week post-op and then in a cam walker for three weeks. There may be some residual tenderness in the area as the foot learns to "adjust" to the implant, but in most cases it will subside over time.

If your doctor has recommended this procedure to you, it would be worth your while to consider as it is not difficult to perform and could have lasting improvement in your ability to walk.

orthotics for flat feet

Generally speaking, orthotics are the most common treatment for flat feet. Having said that, because of the differences in the types and degree of flat feet, there is not one simple solution or recommendation. If you feel that you have flat feet and they are the cause of your pain anywhere from your feet to your lower back, going out and trying an inexpensive pair of "arch supports" from a drugstore of supermarket is certainly not a bad idea.

If that solves your problem, fine. If it does not but you do notice some degree of improvement, that should tell you that a custom or prescription orthotic might give you better relief. At that point, a consultation with a podiatrist might not be a bad idea.


Mayo Clinic


Cleveland Clinic

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ORTHOTICS for multiple types of foot pain
best buy in a pre-made orthotic
click link below


ORTHOTICS for heel and arch pain for those who must wear dress shoes
click link below


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Hunterville, NC
….after reviewing your amazing site (great for the avg. jill). So thank you very much!!!


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Ontario, Canada
I found your website and articles most interesting.


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(location unknown)
I came to your website, via www.foot-pain explained .com which I think is also your website? I thought explanations for different types of problems were well addressed and thoughtfully stated for the patient in mind.


New York
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Memphis, TN
Thanks again so much for the information in the article. Very interesting.


Great article. I have had plantar fasciitis since I was in high school……..

J. Simmons

(location unknown)
Dear Dr. Mitnick, The orthotics arrived four days ago and I slipped them into my shoes immediately. I was skeptical as to the usefulness of the item, they really didn't look very exotic. I have to say though, after using them for just four days, I have experienced grand relief from my foot pain. Even the very first day, I was able to do a lot of work while on my feet with at least a 75% reduction of pain. It has only gotten better every day, and I go nowhere without my shoes with the orthotics. I had been experiencing extreme heel and sole pain for about six months and had to take extended breaks off my feet many times a day as well as regular doses of Ibuprofen. Since getting the orthotics, my life has returned to normal and I feel good again. Just wanted to say thanks for the recommendation for a very effective item, I had no idea what a change this item could affect.

Yours truly,

J.C. Forbes

Thanks for the Response, you hit it on the head.


Redondo Beach, CA
Thank you for your time and expertise in answering my question…..


(location unknown)
First, thanks for putting together this website. Its the most informative site I have found dealing with foot problems. Last June I started having pain and swelling at …….


(location unknown)
First of all, thank you for having all this useful information available in one place. I've been through most of your website and based on my research, pain and evaluations I think I've narrowed things down quite a bit.

Pete M.

(location unknown)
Thank you for the best site I have found when researching foot pain.

Glenda B.

Madison, Alabama
Thanks for replying so quickly. I was a bit concerned. I think your website is great, and chock full of info.....


Denison, TX
Dr. Marc, Thank you so much for your reply which seemed to be right on. I have researched many sites but you put me on the right path to the possible answer. My foot pain may not rule the rest of my life after all! I believe I'll make a sign that reads, "THE END IS NEAR!" Thanks Very Much,


West lafayette, IN
Dear doubt you get positive comments re your site...May I please be added to the list of your admirers. In all of my years of web surfing I would say your site is right there with the very best. Thank you for taking the time to write the terrific info you provide and for putting things into laymen terms for us mere mortals. I pray you have much on going success and thank you again for a deed well done. As for me I did not find much help for my symptoms and will continue on my quest. Were you anywhere in the South I would make and appointment...Thanks again dear sir...m.e.

Michael E.

Tampa, Florida 33624
Hi. This is a great site! I'm a healthy middle aged woman who is in good health, but.....


Just a wee word of thanks for your wonderful website...It is a terrific service...Thank you for providing your knowledge and help...With highest regards, m ebeling

Michael D. Ebeling

Tampa, Florida 33624

Thanks for a most interesting website, which has helped a lot.



Dear Dr.Mitnick

I usually do my research on the Mayo clinic website. I think your website is the most informative site I have found when researching foot pain.

I thank you for putting together this incredible website.


Dragica W.


....I have been told that it is not hard enough to be cut off. Please help, I am not sure what to do now! THANKS FOR A WONDERFUL AND VERY HELPFUL SITE!


South Africa

You have an unusually clear, informative and well-written website for laypersons. Thank you for that.

Matthew W.

Mansfield Ctr, CT

First, I'd like to thank you for all the information that you provide on your website and the opportunity to write to you.


Placentia, California

First, I want to let you know that you have the best web site I've found related to foot issues. (The only thing I had difficulty finding was the "ask a question" page.)


Unknown location

I received the orthotics Monday afternoon and began wearing them Tuesday. After two days I would say that I have noticed a huge improvement in the discomfort I have been experiencing. My foot feels better than it has in months.

Ric J.

Unknown location

I greatly admire someone like you who would donate and dedicate so much time and effort to helping strangers with no compensation. Truly, it is uncommonly kind. And your site is so intelligently arranged.

Ron R.

Pacific Grove, CA

I used to work for a podiatrist (front desk) back during summers in college years ago, so I know the benefits of good care. Again, I want to thank you for an EXCELLENT website. It was so great to get to your site (top of google search) and actually find all the answers I needed EASILY and QUICKLY! Clearly you put a ton of work into it and I really appreciate it.

All the best,


Alameda, California

By the way, millions of websites could use yours as a guideline on how to organize information and make the site user-friendly. Kudos to you!


Thank you for your very interesting and informative site!


Hi. I come to your site often looking for information. It is really informative and I appreciate it very much. I have RA and have been having considerable amount of foot pain...... Dee RN

Thanks very much for the wonderful informative site.


New Zealand

Thank You for my answer! I have been schedule for a bone density scan, allingment, and I am in the process of getting orthotics made, and checking out the natural remedies. Thank again! What a great web site!



Yes I want both pair of orthotics. You don't have an option of ordering 2 at one time so I had to place the order twice. Thanks. My husband likes these and wants to put them in all of his shoes. (referring to Superstep orthotics)

Cindy H.

I searched the internet everywhere for a clear description and illustration of my symptoms/problem. was where I ended my search with answers. If I lived in Jersey (left 30 years ago) and didn't live in Florida I would definetly make an appointment with Dr. Mitnick.

Thanks, Kathy

1st of all THANKS A LOT for your great site......


Thank you so much for your response. I will let you know how I am doing if you would like. Your website is awesome!


South Carolina
Hello! I want to thank you for such an informative website! I found you based on my ankle pain search and am happy to realize that there may be a relatively simple cause and solution....


unknown location

...Thanks for your fantastic service.


Arlington, VA

Thank you so very much, that would be much appreciated. I love those insoles, by the way. (referring to Superstep orthotics)

Kelly W.

San Clemente, CA

Dr Marc is fantastic...He seems to know exactly what you are feeling with the problems you are having. I wish he was in my home town so I could go to him with my problems!!!!!!!!!!!!!


location unknown

Great insights! Thanks Doc, you're the best.


location unknown

I have been experiencing foot pain of various sorts and am working to figure out what it is. I found this site and can only say BRAVO!! What an excellent site! The time it must have taken to put all this together must've been a daunting task! I am sure it has helped so many people. Thank you so very much for doing this.


location unknown

Dr. Mitnick, Thank you so much for your reply. I did let my physician know and they took an x-ray - all is well! Also, thank you for providing this wonderful site, it is very helpful with lots of useful information! I appreciate your gift of time! God bless.


Dr. Mitnick, Thank you, you were 100% correct. The pain finally brought me to the ER. I spent 8 days in the hospital. The Doppler you spoke of was able to show that there was no pulse in that foot. This was an arterial clot that split and traveled throughout my leg. My leg was almost amputated. I am in rough shape but have all my parts intact!! You certainly know what you are talking about. Thank you for taking the time to answer. Yours Truly!


Staying at home after hallux surgery I spend quite a lot of time seaching info useful for avoiding problems which might come back. Today I found your site and I am .... delighted it happened. It's one of the best site I found last days.



Thanks for taking time to read and answer so many questions. It is truly a public service!


Seattle, WA

I just wanted to say that I am very greatful for this website!!


location unknown

Also, and importantly, just want to praise this web site. Thorough and thoughtfully presented, it certainly must be of considerable assistance to anyone with a foot problem. Terrific -- and very interesting.I trust the address comes up easily for those seeking information.


New Jersey

Thanks so much for answering my question. You've been more help to me than my own Dr. has been lately. Thanks again....I hope to be able to walk without pain someday.


location unknown

Wow, that is exactly the information needed!!! thank you thank you thank you!!! I appreciate this help so very much from Marc Mitnick DPM. Excellent information and help to improve One's life.


location unknown

Thanks so much for this website Dr. Marc! It is so nice that you have this ask the doctor feature..I'm sure I'ts been helpful for alot of people. I will try what you suggested and see if it helps...thanks again!


Evansville, IA

Dear Marc

I just want to say thank you for the quick response and the good info. I find it amazing and a super nice thing that you do here by answering medical questions at no charge.

Russ W.

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Your website is full of a lot of helpful information, and I am very impressed with the time in which you responded to my post. Thank you again for your time and consideration in your response.


location unknown

Thank you very much for the information, I will consider it. Excellent web site.


San Diego, CA

Dr. Mitnick, Just want to say thank you so very much for your quick response and very informative reply! After reading what you had to say, I called the doctor's office and was able to get in and see him the same day as my injury. Toe was x-rayed and luckily, it is not broken or fractured. Very badly bruised and will probably lose the toe nail. And although my toe and toe nail are still very black and blue and very sore, they ARE both starting to feel a little better. So again, thank you! I am so very happy that I came across your website. The service you provide is outstanding and immeasurable!


Albany, NY

Thank you so much for all of your advice. In searching the web for people dealing with this same issue i can tell you that you are a Knight In shining Armor! If I lived in Jersey I would gladly be your Spokesperson. Hopefully next time you hear from me it will be good news. God Bless,

Jill S.

location unknown



Whichita, KS

thanks again, this site is very helpful.


Boston, MA

Like others have stated...This site is amazing and I am so thankful that it was created.

....Keep up what your doing. Your a life saver.



Thanks again for the information provided on your site. It's easy for non-medical folk to understand your writing, and helps provide better communication between patient and doctor.



Wonderful advice

by: Anonymous

This is the best site for foot problem info.

Thank you for this information. This description fits my pain and inflammation behind my 2nd toe perfectly.

by: Max

location unknown
Again, I really appreciate that you responded to my inquiry, and that your mention of Parkinson's helped me to find my way to a diagnosis of this difficult to diagnose disease. Most patients see on average 16 doctors before they are diagnosed. I hope that you can help other people that ask for your expertise in the future.

Barb D.

I just wanted to say that I am very greatful for this website!! I have had a fusion in my rt foot and am finally getting a little bit better......


location unknown
Again, Thank you from the bottom of my heart for taking the time to answer my question....your an angel!


Thank you for your response. You have provided some great insight (to my question)....


location unknown
Thank-you so very much for responding so quickly and in such detail to my question!! I will give my surgeon a call today!! This website is terrific!!!! Thank-you again!


North Carolina
Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...


location unknown

Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.

Bessie Mae

Dear Dr. Mitnick, Thank you so very much for taking your time to answer my question. You have greatly relieved my anxiety related to the continual tingly I feel in my feet. I will share your response with my podiatrist next week. God bless you for having this question and answer page on your website! Most gratefully,

Lynne T.

location unknown
Your webpage is excellent, I commend you on sharing your knowledge to the public.


New Jersey

Thank you. you were more detailed than what others have told me they finally called from the last xrays and my son is now in a cast for 2 weeks he did have a fracture that was not noticeable.

a mom

location unknown

I have read your website and I have to admit that I am amazed at all the information that is on here. I have learned more than the three years I have been going to several doctors that I have seen!!


Lenoir, NC

Thank you so much Doc for a quick and thorough response!


Bellevue, WA

I cannot thank you enough for your response, opinion, and suggestions! I want you to know how much it means to me, and I'm sure everyone else who has ever asked you a question! I feel like you're a lifesaver and have empowered me to take a stronger role and stand up for myself and my feet!


location unknown

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